Download About the Disorder What You May See

Early Childhood
Mental Health Fact Sheet
Adjustment Disorder
About the Disorder
What You May See
Adjustment disorder is a change or regression in behavior or
emotions in response to a specific environmental change in a
child’s life. A child struggling with this disorder will respond
to the stress of change in a way that is excessive when
compared to what is considered normal for that child. This
disorder may also appear in children who are going through
a change in placement. For example, a child who moves to a
new foster home or is adopted into a new home—even the
most wonderful, loving home ever imagined—may
experience an adjustment disorder. Adjustment Disorder can
manifest itself as anxiety, depression, or it may be indicated
by behavior that is uncharacteristic for specific a child.
Children who are fussy and act out for a week when their
parent returns to work are not showing signs of an
adjustment disorder. They are experiencing new rules, new
hours, and possibly a new feeding schedule and may,
predictably, seem unsettled. A child who develops intense
separation anxiety or is noticeably sad and/or withdrawn
for an extended period of time after a significant family
change, however, may be experiencing an adjustment
disorder.
There is not a specific type of event that will necessarily lead
to an adjustment disorder, and not all children will respond
to unsettling events in the same way. For example, an
unsettling event could happen to several children—even
children in the same family—but only one of the children
may experience an adjustment disorder. The way a child
responds to an unsettling event may also be affected by a
child’s cultural background and everyday experience.
Adjustment disorders occur in both males and females and
can occur in children of all ages.
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
Infants and young children have little control over many
aspects of their daily life. They do not, for example, decide
where to live, which childcare they will attend, or how long
they will stay at childcare. Changes in these areas, as well as
stressors such as major illness, parental divorce, birth of a
sibling, and excessive marital conflict, can lead children to
develop an adjustment disorder. In response to these
changes, a child who usually plays happily may become
aggressive; a child who often plays alone may begin to
engage other children in a negative way; a child who
typically is very good natured may become upset easily and
begin to have tantrums; and a child who has mastered a
developmental milestone, such as toileting, may regress.
Children are wonderful observers of their world, however,
they are not always accurate interpreters. When a child begins
to appear stressed, parents and caregivers often find clues to
the child’s behavior when they are able to see the world from
their child’s perspective. Events that may not seem disturbing
to adults, such as the birth of a new child, may affect children
differently. It is often not the change itself but the child’s
perception of the environmental change that causes the stress
and, sometimes, a subsequent adjustment disorder.
Symptoms
A child with Adjustment Disorder may exhibit one or all of
the following:
• Appear subdued, irritable, anxious, or withdrawn
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
• Resist going to sleep
• Have frequent tantrums
• Regress in the ability to toilet independently
• Have increased separation anxiety
• Exhibit acting-out behaviors that are uncharacteristic for
the child such as hitting or biting
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Adjustment Disorder
(continued)
Strategies
Documenting Your Concerns and Next Steps
Life can, at times, present unavoidable conflicts and
difficulties. Although we cannot always control our
children’s environment, we do need to be attuned to when
environmental changes begin to negatively affect the children
in our care. Whenever possible, anticipating upheaval and
preparing a child for changes in routines can often help a
child to maintain a sense of security. Mentioning an
anticipated change in a calm, relaxed way several times
before the actual change takes place can reassure a child that
although change may feel unsettling, their world will remain
safe and secure.
When documenting behavior, avoid generalizations such as
“the child appears depressed or anxious”; instead, record
specific behaviors you are seeing or not seeing. For example,
“Caleb did not want to participate in art time; we were using
finger paints today, which is typically one of Caleb’s favorite
activities” or “When we went outside, Caleb sat in the
sandbox but did not climb or slide as he has done almost
every day since joining our group” or “This is the third day
in a row that Caleb has had trouble falling asleep at nap
time.” Also note what happened before and after the
behavior. For example, did Caleb have a disagreement over
a toy before art time.
Some changes in a child’s environment are completely
unexpected and may even cause the child’s caregivers to
have difficulty adjusting to the new circumstance. When
unanticipated events disrupt a child’s environment, allow the
child time to get used to whatever has changed. For example,
a preschool teacher may suddenly come down with a serious
illness and be unable to return to the classroom for several
months. In this case, take time to introduce any new teachers
to the children and explain that the previous teacher may not
be coming in for a while. Be sure to use a calm and selfassured manner. Children are pretty good at sensing when
an adult is unsettled. Avoid lengthy explanations about what
has occurred—children don’t usually need in-depth
explanations; they usually just need to be reassured that
someone is in control and that their life will go on with as
little disruption as possible.
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
Ready Resources
• Kami M. Talley Reading and Resource Center at the
University of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• ZERO TO THREE at www.zerotothree.org
Information included in this fact sheet comes primarily from the DC:0–3R (Diagnostic Classification of Mental Health and Development Disorders of
Infancy and Early Childhood: Revised Edition).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Anxiety Disorders
About the Disorder
All young children feel anxious at times. Many infants and
toddlers, for example, show great distress when separated
from their parents, and preschoolers are often frightened of
strangers, thunderstorms, or the dark. These anxieties are
normal and are usually short-lived.
An anxiety disorder occurs, however, when a child
experiences excessive worry, concern, or fear while involved
in developmentally appropriate tasks, ordinary interactions,
and everyday routines. Anxiety disorders in children are
characterized by worry, concern, or fear that is exaggerated,
pervasive, disproportionate to the situation at hand, and
inappropriate for the child’s age or developmental level.
There are many types of anxiety disorders—here are the most
common.
• Generalized Anxiety Disorder
Children experience excessive anxiety and worry more days
than not for a period of more than six months. These children
may have difficulty concentrating and/or difficulty falling or
staying asleep. They often appear on edge or irritable and
may have a more difficult time maintaining emotional
stability. The child’s anxiety and worry will interfere
significantly with their functioning and/or development.
• Separation Anxiety Disorder
Separation from the caregiver causes the child excessive
anxiety and distress that has intensity and duration beyond
that of typical development and lasts more than one month;
children experiencing this disorder often refuse to be held or
comforted by a substitute caregiver. These children are also
Early Childhood
Mental Health Fact Sheet
often preoccupied with fears that their primary caregiver will
have an accident or become sick; the child may also fear that
they might have an accident or illness while separated from
their primary caregiver. Children may also worry about
getting lost or kidnapped. Physical complaints such as
headaches, stomachaches, nausea, or vomiting are also
common when separation from the caregiver occurs or is
anticipated.
• Specific Phobia
Children experience excessive fear when they are in the
presence of specific objects or exposed to certain situations; the
fear may even occur when the child is just anticipating such
experiences. The fear must last at least four months. Exposure
to the object or situation will cause an immediate reaction by
the child—usually crying, a tantrum, becoming immobile, or
becoming “clingy.” The child will attempt to severely limit
their own activities and their family’s activities to avoid
possible exposure to the feared object or situation.
• Social Anxiety Disorder (Social Phobia)
A child will have a persistent fear of social or performance
situations that include people unfamiliar to the child or the
child will be in a situation where they are under the scrutiny
of others; this typically includes such things as play dates,
large family gatherings, birthday parties, religious
ceremonies, and/or collective sharing times at childcare or
preschool; the fear must last at least four months. These
situations may cause reactions such as crying, having a
tantrum, becoming immobile, becoming clingy, or strongly
resisting being involved in social situations. The child will
avoid the feared social situation and may have anticipatory
anxiety that interferes with their normal functioning and
development.
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
• Anxiety Disorder NOS (Not Otherwise Specified)
Although not often used, this category may be used when a
child exhibits some symptoms of an anxiety disorder but,
taken together, the symptoms do not fulfill the diagnostic
criteria of a specific anxiety disorder. A parent or caregiver
may see uncontrollable crying or screaming, agitation and/or
irritability, sleeping and/or eating disturbances, separation
distress, or social anxiety. Caregivers should be careful to
notice if the onset of the symptoms occurred after the child
endured a trauma; in that case, the child may be at risk for
posttraumatic stress disorder.
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Anxiety Disorders
(continued)
What You May See When
Children with anxiety disorders usually exhibit an excessive
level of fear toward normal challenges and/or when learning
new skills.
Infants may display anxiety by crying
inconsolably or screaming; sleeping and eating disturbances
may also indicate a higher level of anxiety. Toddlers and
preschoolers experiencing an anxiety disorder may exhibit
recklessness and aggression directed toward themselves or
others. For example, a toddler may be so afraid of the dark
that the lights being turned down at nap time cause him to
aggressively run from the room, or a child may become
aggressive and run reckless when confronted with a new but
developmentally appropriate activity such as finger painting.
It is also common for children to react with somatic
complaints such as stomachaches or headaches.
Symptoms
• Multiple fears
• Specific fears
• Limited play repertory
• Difficulty with transitions between activities
• Reckless and defiant behavior
• Excessive stranger anxiety
• Excessive separation anxiety
• Excessive inhibition due to anxiety
• Lack of impulse control
Strategies
• Avoid belittling the fear or anxiety; instead, validate the
concern without confirming that the fear is real. For
example, “You are worried about your dad leaving—that
can be scary to think about.”
• Use and teach positive self-talk; listen to what the child
says and help them to replace negative thoughts with
positive ones. For example, if your child says “I can’t go
outside because their might be a dog and dogs are scary,”
you can say “Some dogs outside are mean and may be
scary, but not all dogs are. I’ll help you figure out which
ones aren’t mean so you can feel okay outside.”
• If the anxiety is around learning or mastering new skills,
teach building-block skills. For example, if a child seems
overwhelmed at the thought of getting dressed by
themselves, teach them to zipper or button first, then work
toward the goal of independent dressing over time.
• For separation anxiety, try using a transitional object—
something the child receives from their caregiver to hold
while the caregiver is gone.
• Help the child verbalize their feelings and fears. With
young children, help them to distinguish between a little
bit scared and a whole lot scared.
• Teach relaxation and deep-breathing exercises to children
who are able to understand and participate in these
activities. Blowing bubbles and pretending to blow
bubbles, learning to whistle, or actively trying to move
their bellies in and out are all fun ways for children to learn
deep breathing.
Documenting Your Concerns and Next Steps
When documenting behavior, be as specific as possible and
avoid generalizations such as “Shayla looked anxious.”
Instead, record specific behaviors you are seeing or not
seeing and provide as much detail as seems relevant. Also
include the context in which the behavior occurred. For
example, noting that “Shayla held her blanket tight and got
teary-eyed as the children lined up to go outside” is more
informative than “Shayla wouldn’t line up to go outside.”
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
Ready Resources
• Anxiety Disorder Association of America at www.adaa.org
• Kami M. Talley Reading and Resource Center at the University
of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• ZERO TO THREE at www.zerotothree.org
Information included in this fact sheet comes primarily from the DC:0–3R (Diagnostic Classification of Mental Health and Development Disorders of
Infancy and Early Childhood: Revised Edition).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Attention-Deficit/
Hyperactivity Disorder
(AD/HD)
About the Disorder
Although the symptoms of Attention-Deficit/Hyperactivity
Disorder (AD/HD) can sometimes appear in preschoolers,
the diagnosis of AD/HD in preschoolers is very difficult.
Many of the symptoms required for an AD/HD diagnosis—
difficulty sustaining attention and effort, lack of attention to
detail, seeming not to listen, difficulty following through on
tasks and instructions, disorganization, distractibility, talking
excessively, difficulty waiting one’s turn, and interrupting
others—are actually developmentally appropriate behaviors
for young children who are in the process of learning impulse
control and self-regulation. To further complicate matters,
language delays, developmental problems, anxiety,
depression, and adjustment disorders are all things that can
imitate AD/HD.
Of course, some preschool children actually do have
AD/HD, and they need treatment and intervention. For
these children there will likely be a qualitative difference in
the way they exhibit the behaviors listed above. Because the
symptoms of AD/HD are similar to developmentally
appropriate behaviors and can be imitated by other health
concerns, it is exceedingly important that qualified and
skilled professionals conduct the assessment of very young
children. In fact, preschoolers suspected of having AD/HD
may need to be evaluated by a pediatrician, psychologist or
psychiatrist, neurologist, speech pathologist, and/or
developmental pediatrician to develop a full understanding
of a child’s behaviors.
Although pinpointing an actual diagnosis may be a difficult
and complex task, helping a child develop proper social and
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
Early Childhood
Mental Health Fact Sheet
academic skills during early childhood can be crucial to their
future success.
What You May See
Most children have more energy than adults—they can play
hard all day long and still not seem tired. Some children do
have a naturally higher energy level than others, but a
preschooler with AD/HD will likely have more difficulty
sitting and listening to a story, they may behave more
aggressively toward other children when they get distracted
or bored, or they will interrupt much more often than other
children. And although the early years are a time when
children naturally struggle to learn impulse control, children
with AD/HD will have a more difficult time learning to
control their impulses.
AD/HD in the Early Childhood Years
Although the revised Diagnostic Classification of Mental
Health and Development Disorders of Infancy and Early
Childhood (DC:-03R) does not list diagnostic criteria for
AD/HD, we are providing a fact sheet about it because of the
increase in the number of children younger than age 5 who
are being diagnosed and treated for the disorder.
The American Academy of Pediatrics recognizes that AD/HD is
difficult to diagnose in this population because young children
are developing so rapidly and because many children display
symptoms of AD/HD as part of their typical development in
their early years. Despite this acknowledged difficulty,
epidemiological data suggests that approximately 2 percent
of children aged 3—5 years meet diagnostic criteria for
AD/HD.
In fact, a 1990 review showed that 34 percent of pediatricians
and 15 percent of family physicians had prescribed psychostimulant medications to preschoolers with AD/HD. Other
studies indicate the growing use of stimulants in preschoolers
during the 1990s.
Stimulant medication treatment in
preschoolers increased approximately three-fold in the early
1990.
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Attention-Deficit/Hyperactivity
Disorder (AD/HD)
(continued)
Symptoms
Documenting Your Concerns and Next Steps
• Difficulty sustaining attention and effort
When documenting behavior, be as specific as possible and
avoid generalizations like “Pete is always hyperactive”;
instead, record specific occurrences. Here’s an example: “At
lunch time, Pete was reminded three times of the clean-up
chores that follow lunchtime. When Pete finished his lunch,
he left the table and began playing without washing his
hands, busing his dishes, or taking off his bib. When I
redirected him to do the clean-up chores, he threw his plate
on the floor and then sat down and screamed.” That is a
much more complete picture than, “Pete can’t stay focused
on tasks he is asked to do.” When noting worrisome
behaviors, also look for patterns and areas of development
where the child may need additional teaching. Does the
child need different teaching methods or to learn skills in a
different order than other children?
• Lack of attention to detail
• Seemingly unable to listen
• Difficulty following through on tasks and instructions
• Disorganized
• Easily distracted
• Talks excessively
• Has difficulty waiting one’s turn
• Interrupts others
• Lacks impulse control
Strategies
• Be patient and stay calm if the child is acting out.
• Teach the behaviors you would like the child to exhibit.
Understand that the child may be practicing new skills
and have patience.
• Teach calming skills such as deep breathing exercises.
Blowing bubbles and pretending to blow bubbles, learning
to whistle, or actively trying to move their bellies in and
out are all fun ways for children to learn deep breathing.
• Teach strategies for impulse control—for example, say “I
know you are excited to take a turn, why don’t you march
in place until your turn.”
• Play games that teach the child to anticipate what may
happen next.
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
• Give the child plenty of time to respond when working to
solve a problem.
• Provide structure and clearly define expectations.
• Give one direction at a time, for example, say “Let’s put
the toys away” instead of “Pick up your toys, get your
boots, and then we will go outside to play.”
• Sharing books like Jumpin’ Johnny Get Back to Work!: A
Child’s Guide to ADHD/Hyperactivity by Gordan Michael
can sometimes be helpful.
Ready Resources
• Children and Adults with Attention-Deficit/Hyperactivity
Disorder at www.chadd.org
• Kami M. Talley Reading and Resource Center at the
University of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• National Institute of Mental Health at www.nimh.nih.gov
• ZERO TO THREE at www.zerotothree.org
Information included in this fact sheet came primarily from the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Early Childhood
Mental Health Fact Sheet
Depression
About the Disorder
Most children will, at some time, show signs of sadness, be
whiny, or engage in their play halfheartedly. These times are
usually short-lived and can often be linked to an oncoming
illness, boredom with an activity, or a minor disruption in
their routine. However, when these feelings or behaviors are
consistently evident for longer than two weeks, the child may
be suffering from depression.
Depression in children can be experienced in different ways.
Some children may experience a low-grade feeling of sadness
and/or lethargy nearly all the time, while others will
experience intense periods of sadness that come and go.
Regardless of the type of depression, research findings
suggest that depression in preschool-aged children is
typically characterized by symptoms of sadness and/or
irritability. The symptoms, however, can look different—one
child may appear sad and withdraw from activities, while
another child may appear irritated and aggressive. In
addition, children may exhibit joylessness—even though
they may be engaging in playful activities, they will not be
having fun.
In young children, these symptoms may be somewhat
difficult to recognize because infants and toddlers don’t
always have clear ways to indicate these somewhat complex
feelings. Actually depression can be especially difficult to
recognize because some of its symptoms are similar to some
of the cues infants use to get their everyday needs met. For
example, an infant who is fussy or whiny may be getting in
their first tooth and may need extra comforting. However, as
a child’s skills develop and their personality emerges,
caregivers may be able to gain a clearer understanding of the
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
child’s usual temperament. Therefore, as a child matures, the
ability to recognize depression as a change from the child’s
normal behavior may become easier.
What You May See When
In very young children depression may appear as irritability,
isolation, consistently aggressive or destructive play, or being
accident prone. Extreme anxiety may also be noted. These
indicators must be a change from the child’s usual emotional
state. With depression, the depressed mood or sadness will
occur across settings and activities and impede the child’s
development or impair their functioning.
When — Infancy
What — A baby experiencing depression may be whiny,
lethargic, show signs of sadness, or play half-heartedly; their
sleep patterns may be disrupted and they may lose weight.
These children may either sleep more than usual or be more
wakeful than is normal; they may also lose interest in their
favorite toys.
When — Toddlers & Preschoolers
What — Toddlers and preschoolers, along with the
indications above, may express feelings of sadness verbally
and tend to be socially withdrawn. They may also complain
of headaches or stomachaches, seem apathetic, have trouble
concentrating and /or regress in some skill areas. For
example, they may have trouble paying attention, have
trouble solving problems, or they may even engage in
creative play that offers clues about their feelings.
Symptoms
• Depressed or irritable mood
• Diminished interest or pleasure in developmentally
appropriate activities
• Reduced capacity to protest (may seem apathetic)
• Emotional withdrawal
• Lethargic
• Sad facial expression
• Regression in skills
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
• Regression in developmental milestones
• Excessive whining
• Reduced repertory of social interactions
• Change in sleep patterns
• Weight loss
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Depression
(continued)
Strategies
• When developing strategies for a child who is exhibiting
symptoms of depression, remember that acknowledging
feelings is critical to emotional development.
• Allow the child to initiate play, then be sure to show
interest in the objects they select for play.
• Allow the child time to express their needs and wants—
then relay back to them what they said and ask the child if
you have accurately identified how they feel.
• Verbalize emotional expression with the child (for
example, “Your face looks happy, are you enjoying this
story? Your body looks frustrated, do you need help?”)
Helping Children Express Their Feelings
Because all children—even those who never experience
depression—will have feelings of sadness at some point, it is
critical to engage in activities designed to help them
recognize and express their feelings and emotions
appropriately.
By about age 3 children are able to verbally label their own
emotions, identify emotional states from pictures, and link
emotions to social situations (The birthday party made me
feel excited!).
Preschool children may also begin to
understand the experience of more than one feeling at a time,
including the experience of conflicting emotions.
The
capacity to understand and experience emotions continues to
increase during the preschool period. By age 5, children are
learning to verbalize rather than act upon feelings, and they
are gaining important insights into self-regulation.
Caregivers and others involved in children’s lives can help
support this development. For example, when a caregiver
acknowledges that a child is feeling mad, sad, frustrated, or
tired, the caregiver can offer the child the support they need
to be able to release tension and begin to problem solve.
Trusted adults can also help children focus on positive
thoughts and actions rather than negative ones by teaching
positive self-talk and coping strategies. Another excellent
way to teach about emotions is to regularly express your own
feelings of anger and frustration (“I’m feeling frustrated right
now”) as well as feelings of joy and happiness (I’m feeling
happy about going outside to play) in very simple and easy-tounderstand language. This will help them be better able to
deal with a wide range of emotional experiences.
• For infants who seem sad or depressed, be sure to hold,
comfort, rock, and sooth them.
• In group situations, avoid games that may be socially
isolating, such as one that requires picking teams.
• Openly give encouragement and positive reinforcement.
Documenting Your Concerns and Next Steps
When documenting behavior, always be specific. Avoid
generalizations such as “Grace looked depressed” or “Kyle
seems really sad this week”; instead, record specific
behaviors you are seeing or are not seeing. For example,
“Kyle looked away when I held his favorite sparkly keys this
morning. He did not appear to want to play with any of the
toys; he fussed and looked away with each one I offered him.
I held him and rocked him, but he made very little eye
contact with me and did not seem soothed by my singing.
This is the 5th day that Kyle has exhibited this very
uncharacteristic behavior.”
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
Ready Resources
• iFred—the International Foundation for Research and
Education on Depression at www.ifred.org (formerly
www.depression.org)
• Kami M. Talley Reading and Resource Center at the
University of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• ZERO TO THREE at www.zerotothree.org
Information included in this fact sheet comes primarily from the DC:0–3R (Diagnostic Classification of Mental Health and Development Disorders of
Infancy and Early Childhood: Revised Edition).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Deprivation/Maltreatment
Disorder of Infancy and
Reactive Attachment Disorder
About the Disorder
Deprivation or maltreatment disorder of infancy is
characterized by disturbed and developmentally
inappropriate attachment behaviors in which a child rarely or
minimally turns to a specific attachment figure for comfort,
support, protection, and nurturance. This disorder may
develop when a child has a limited chance to form a primary
attachment. Circumstances that can result in a child
developing this disorder include frequent changes in
caregivers, child abuse and neglect, or the unavailability of
an attachment figure—for example, if the child is in an
institution or if the attachment figure has a substance abuse
problem or is experiencing severe depression.
Early Childhood
Mental Health Fact Sheet
participate in social and emotional turn-taking or sharing.
The child may appear depressed or emotionally withdrawn.
• Indiscriminate or disinhibited pattern
The indiscriminate or disinhibited child will not form
selective attachments but will seemingly attach to relative
strangers. The child may behave in an overly familiar way
with any adult. For toddlers and preschoolers, the absence of
checking in with a caregiver when exploring unfamiliar play
spaces and a willingness to go off with unfamiliar adults are
both characteristic of this pattern.
• Combination of the two
A change or improvement in the caregiving situation will
usually lead to some remission of the symptoms.
This child will exhibit characteristics consistent with both the
emotionally withdrawn/inhibited pattern and the
indiscriminate or disinhibited pattern.
What You May See When
Symptoms
A young child with a deprivation, maltreatment, or
attachment disorder will usually follow one of three patterns
of behavior. At times a child’s behavior may fit one of the
patterns listed below, but the behavior may be due to a delay
or disorder of relating and communicating rather than to
deprivation or maltreatment.
Note: A child may exhibit some but not all the symptoms listed here.
• Emotionally withdrawn or inhibited pattern
A child with the emotionally withdrawn or inhibited type
will rarely seek comfort when feeling stress. Whether the
disorder becomes apparent in infancy or during the toddler
years, these children will not respond to efforts made to
comfort or reduce stress. The child may show excessive
levels of irritability, sadness, or fear, and typically will not
Emotionally Withdrawn or Inhibited—This may look like a
depressive disorder and is difficult to distinguish, but
remember the child will lack an attachment figure.
• Does not seek comfort when feeling stress
• Attachment behaviors, such as cooperation, showing
affection, and reliance on others for help seem to be
missing or very restricted
• Appears emotionally blunted
• Frozen watchfulness
• Avoids or fails to respond to social cues
• Does not initiate social interactions
• May resist comforting
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
Indiscriminate or Disinhibited
• Lacks the typical social shyness around unfamiliar adults
that is typical of 2 to 4 year olds
• May resist comforting by primary caregiver
• May seek proximity and comfort indiscriminately, even
with strangers
• Lacks the ability to protect themselves (willingness to go
with strangers)
Mixed Deprivation/Maltreatment Disorder—This will have
symptoms from both patterns of behavior.
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Deprivation/Maltreatment Disorder
of Infancy and Reactive
Attachment Disorder
(continued)
Strategies
Documenting Your Concerns and Next Steps
• Make sure the child has a sense of security and receives
consistent nurturing while they are in your care.
When a caregiver does become concerned about a child’s
behavior, it is important to record in as much detail as
possible the frequency and intensity of the behavioral
difficulties so that there is a greater the chance of
understanding the problem and arriving at workable
solutions. A caregiver may worry about the care a child is
receiving. Often it helps to write out a list of concerns and
keep a log of behavior concerns or behavior changes in the
child.
• Empathize with the child and understand the child’s
reluctance to form an attachment; try not to take it
personally and continue to engage the child.
• Provide a secure and trusting relationship—for example,
tell the child that you are there for them and that you care
about them. And follow up your words with acts of
caring. Take advantage of every opportunity to comfort
the child when they are experiencing difficulty by being
their ally when they are faced with stressful situations.
Whenever possible, give the child loving attention—for
example, read to them, tell them stories, or sing to them.
• Avoid distancing strategies—use “time with” or “time in”
instead of “time out.”
• Show sensitive responses to the child’s invitations for
social interactions, no matter how small the invitation
appears. Even though you may feel rejected by the child,
continue to respond to any invitations by the child to
engage you. If a baby coos, offer a verbal response as well
as a warm smile. When an older child offers to show you
their toy, take a keen interest and make sure the child sees
how much you appreciate their effort to relate to you.
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
• Be emotionally available to the child—for example,
respond to the child’s expressions of emotion, no matter
how small. When the child talks of something that
frightened them or something that made them happy, let
the child know that you understand their feelings—share
in their joy and comfort them when they are frightened.
Child Abuse and Neglect
Abuse and/or neglect is characterized by a caregiver’s
persistent disregard for their child’s basic physical needs,
their emotional needs, and their need for comfort,
stimulation, and affection. When a caregiver neglects or
abuses a child in a physical or psychological way long enough
to undermine their basic sense of security and attachment,
the child may develop an attachment disorder. This neglect
can essentially stop the emotional development of a young
child.
However, because all children have a unique
temperament and internal resiliency, not every child who has
been neglected or abused will experience this disorder.
Note: The presence of neglect or abuse alone does not create
this diagnosis.
Ready Resources
• Family Attachment Counseling Center at www.family
attachment.com
• Kami M. Talley Reading and Resource Center at the
University of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• ZERO TO THREE at www.zerotothree.org
Information included in this fact sheet comes primarily from the DC:0–3R (Diagnostic Classification of Mental Health and Development Disorders of
Infancy and Early Childhood: Revised Edition).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Fetal Alcohol Spectrum
Disorders (FASD)
Early Childhood
Mental Health Fact Sheet
About the Disorder
What You May See
Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term
that describes a wide range of effects that can occur in a child
whose mother drank alcohol during pregnancy. Prenatal
alcohol exposure can cause significant brain damage. The
effects of FASD typically include physical, mental, and
learning disabilities as well as behavioral deficits and
problems with socialization.
An infant with FASD may be very irritable, fussy, and/or cry
a lot for no apparent reason. As a child with FASD grows,
parents and caregivers may begin to notice that the child’s
development of gross motor skills is delayed—for example
the child may walk or run with an awkward gait, have
difficulty tossing and catching a ball, and/or struggle to be
able to hop on one foot. The child may also exhibit cognitive
deficits—for example the child may have trouble problem
solving, difficulty planning future actions, and problems
taking in, storing, and recalling information. Because of
damage to the brain, a child with FASD is sometimes overly
sensitive to sensory input—for example they may be upset by
bright lights, loud noises, and tags on their clothes.
FASD includes the following categories:
• Fetal alcohol syndrome (FAS)—This is indicated by a
pattern of neurological, behavioral, and cognitive deficits
along with specific facial features.
• Alcohol-related neurodevelopmental disorder (ARND)—
This term is used when only central nervous system
abnormalities are present as a result of the fetal alcohol
exposure. ARND is characterized by problems with
memory and motor skills.
• Alcohol-related birth defects (ARBD)—This is indicated by
defects in the growth of skeletal and major organ systems.
• Fetal alcohol effects (FAE)—This term is sometimes used
to describe children who had prenatal exposure to alcohol
but do not have all the symptoms (particularly the facial
features) associated with FAS.
Some children will have no physical symptoms of FAS. If it is
certain that a child was exposed to alcohol before birth but
there are no physical symptoms and the child’s early childhood
screening appears to be within normal development, a followup screening may be necessary when the child is older if
behavioral or learning deficits become apparent.
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
As the child’s development continues, parents and caregivers
may notice that the child has verbal skills that exceed their
level of understanding, which will sometimes lead a child to
say they understand something when they don’t. They are
also likely to have difficulty following multiple directions.
These challenges are frustrating and can lead the child to
emotional outbursts. Along with auditory processing
problems, parents may also see a child develop oppositional
behaviors and a pattern of not completing tasks or chores
they are asked to do.
As a child with FASD has more social interactions, parents
and caregivers may notice that the disorder can cause the
child to misinterpret others’ words, actions, or body
movements, which can make it harder for the child to
determine how to respond to different situations. It is also
typical for children with FASD to miss social cues and be
unable to entertain themselves. This too can lead to social
problems and acting out.
Symptoms
• May cry a lot and be irritable as an infant
• May have tremors
• Sensitive to sights, sounds, and touch
• Easily over-stimulated, then hard to soothe
• Problems with bonding
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
• Inappropriate social interactions (for example willingness
to leave with a stranger or hugging strangers—strangers
can be either child or adult)
• Unable to comprehend danger and does not respond well
to verbal warnings
• Prone to temper tantrums and noncompliance
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Fetal Alcohol Spectrum
Disorders (FASD)
(continued)
Symptoms (continued)
• Difficulty handling changes in routine
• Motor skills lag behind children of the same age
• May be disinterested in food
often helpful in teaching behaviors like social interactions,
waiting in line, and asking for help.
• Use teaching strategies that focus on the child’s strengths;
whenever possible give the child jobs to do that require the
child’s strengths.
• May have disrupted sleep
• Distractible, unable to concentrate, poor memory
• Inconsistent behaviors, skill levels from day to day
• May be able to state a rule but not follow it
• No recognizable play themes or organization
• Has difficulty with requests or instructions that have more
than two steps
Strategies
Because damage to the developing brain varies, each child’s
development will be different; however, the following
strategies work well with many children who have FASD:
Documenting Your Concerns and Next Steps
When documenting behavior, avoid generalizations such as
“Roberto never remembers the rules for circle time.” Instead,
provide observations such as “Each day this week I have had
to remind Roberto that when another child is speaking
during circle time he must raise his hand and wait until the
other child is done.” Often it helps to write out a list of
concerns or keep a log of the situations where the child
appears to have difficulty. Recording the frequency of the
behavior and what the child said and did as well as what the
caregiver said and did can help to identify specific triggers
and/or learning deficits.
• Be consistent and structure the day so there are predictable
routines.
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
• Repeat and re-teach frequently. Rules, expectations, and
directions may not be remembered from day to day.
Review behavioral expectations with the child before each
event.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
• Speak simply and concretely. Avoid words with double
meanings, sarcasm, and irony.
• Give only one-step or two-step directions.
• Simplify the child’s environment and take steps to avoid
sensory triggers.
• Use pictures, charts, and demonstrations. Allow children
to find their own way of performing a task when possible.
• Provide skills training and use a lot of role playing.
• Supervise all activities—children with FASD can be
socially naïve and are easily victimized.
• Use direct teaching of skills that are missing. Materials
similar to those designed for students with autism are
FASD
It is important to approach parents supportively and nonjudgmentally. Although parental confirmation of prenatal
drinking can be vital in obtaining services for a child, it is
sometimes necessary to treat the symptoms (such as
oversensitivity to stimuli or social delays), without raising the
question or needing confirmation of a FASD.
Ready Resources
• Kami M. Talley Reading and Resource Center at the
University of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• National Organization on Fetal Alcohol Syndrome at
www.nofas.org
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• ZERO TO THREE at www.zerotothree.org
This fact sheet is based on information from SAMHSA'S (U.S. Department of Health and Human Services Substance Abuse and Mental Health Services)
FASD Center for Excellence and NOFAS (National Organization on Fetal Alcohol Syndrome).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Pervasive Developmental
Disorders (PDD)
About the Disorder
*For children younger than 24 months, “Multi-System Development
Disorder” (MSDD) is preferred. For more on MSDD, see box on the back
of this fact sheet.
Pervasive developmental disorders (PDD) include autistic
disorder, Rett’s disorder, childhood disintegrative disorder,
Asperger’s syndrome, and PDD-NOS (not otherwise
specified). For children with autism, the disorder will
progress continually; children with other disorders in this
category may develop normally and then experience a
regression. For all disorders of this type, however, the onset
will occur in early childhood, and except for Rett’s Disorder,
which has been seen only in females, the rates of occurrence
are higher in males than in females. This category of
disorders involves a delay in a child’s development of basic
social, communicative, and learning skills.
Early Childhood
Mental Health Fact Sheet
clumsy. They may also have an aversion to affection and/or
physical contact—during infancy this may mean the child
seems uncomfortable when being cuddled.
As the child matures and begins to play with toys, they may
tend to relate to the inanimate environment better than they
relate to people. For example, a child with autism may be
clearly enamored with a certain toy, but will not likely rush to
share the special toy with their primary caregiver. The child
may also seem to have little understanding of the needs of
others and may even seem not to notice another person’s
distress. It is these behaviors that lead to difficulty in
developing friendships and problems with social skills.
Children with this diagnosis may have impairments in the
use of several nonverbal behaviors such as eye contact, facial
expressions, body posture, as well as other gestures used in
social interactions and to communicate. Because every child
is unique and PDD covers a wide spectrum of symptoms and
behaviors, no two children with this diagnosis will behave
the same. In general, however, children with a PDD
diagnosis have difficulty establishing social relationships,
resist change, and need consistent structure and routine.
It may seem that young children with PDD have little or no
interest in establishing friendships. They may even seem as
though they have not formed a secure bond or attachment to
a particular caregiver. As children with a PDD diagnosis get
older, they often desire friendships and express sadness or
depression as they gain understanding of being different.
Early intervention, therefore, is especially important because
it can help them to develop necessary and useful social skills,
communication skills, and cognitive skills. With intense
behavioral intervention, some preschoolers with autism have
achieved higher IQ scores, more expressive speech, and a
reduction in behavior problems.
What You May See
What You May See – At a Glance
In children for whom the onset of the disorder occurs during
infancy, parents and caregivers may notice a lack of socially
directed smiles and that the child does not respond to their
caregiver’s voice. This sometimes leads caregivers to be
concerned that their child may be deaf. Infants may also
exhibit sensory sensitivities, avoid direct eye contact, be
inflexible with regard to routines, and/or they may seem
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
The spectrum of PDD is broad—some of these characteristics may be more
indicative of autism than Asperger’s.
When – Infancy
What – May exhibit sensory sensitivities, avoid direct eye
contact, be inflexible with regard to routines, and/or may
seem clumsy; may reject cuddling.
When – Toddler
What – As a child with PDD matures, the initial indications
may become more pronounced. Beyond avoiding eye
contact, they will avoid direct interactions; language
problems may become more apparent or a regression in
language development may occur; inflexibility with regard to
routine will be more fixed; difficulties in processing visual,
auditory, and tactile sensations may appear; and problems
with vestibular (sense of balance and equilibrium) and
proprioceptive (sense of one’s body in space) sensations may
occur.
When – Preschooler
What – Children at this age may not engage in socially
imitative play or they may engage in limited types of play;
they may also begin to have more pronounced difficulties
with peer relationships.
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Pervasive Developmental
Disorders (PDD)
(continued)
• Teach basic skills such as responding to their name, sitting
with a group, and following directions.
Symptoms and Behaviors
• Inflexible adherence to routines or rituals
• Impairment in non-verbal communication
• Teach social skills like taking turns and looking at the
person you are talking to; if eye contact is too intense, teach
the child to look at a person’s forehead or nose instead.
• Abnormally intense focus or interest in a specific area (for
example, may be intensely focused on vehicle wheels or
may insist that every toy is a guitar)
• Structure playtime to help the child interact with peers (for
example, assign peer buddies or establish cooperative
groups to ensure inclusion).
• Language problems may be apparent—the child may
rarely speak, may be unable to initiate or sustain a
conversation, or may repeat phrases over and over
• Find a creative way to show affection—although some
children with PDD do not like to be touched, some do
enjoy firm hugs.
• Lack of varied play
• Lack of social imitative play typical of developmental level
(for example, will not have tea parties or play store)
• Ask the child’s primary caregiver if there are any strategies
(such as language games the child plays at speech therapy)
that could be incorporated into the child’s play.
• May lack sensitivity to or be highly sensitive to sounds,
lights, smells, touch, and/or the taste and texture of foods
Documenting Your Concerns and Next Steps
• Avoidance of eye contact
Strategies
• Provide a highly structured environment.
• Use graphic or visual schedules.
• Prepare the child for changes and transitions.
Multi-System Developmental Disorder (MSDD)
For children younger than 24 months,
Developmental Disorder (MSDD) is preferred.
Multi-System
A child with MSDD does not totally lack the ability to develop a
social/emotional relationship with a primary caregiver but will
have impairment in developing this relationship. The child may
avoid contact with caregivers, but will give slight cues that show
attachment.
These children have difficulty forming,
maintaining, and/or developing communication, including preverbal gestures. For many toddlers with MSDD, language does
not serve a communicative intent. They may memorize parts of
songs or dialogue but they do not use speech to communicate.
A child with MSDD may have major difficulty processing visual,
auditory, tactile, proprioceptive (spatial awareness of one’s
body), and vestibular sensations. Most have poor motor
planning—they lack the ability to sequence their movements to
create a desired outcome—and may appear very clumsy when
learning a new skill. Infants and toddlers diagnosed with MSDD
also show impairments in processing sensations. For example,
they may be extremely sensitive to touch (startling or even
having a tantrum when touched lightly), or they may show great
pleasure in heavy pressure (being sat on or wedging themselves
in small spaces behind furniture).
Early interventions can be very successful in helping a child with
MSDD develop processing tools and coping strategies.
An
assessment and intervention plan that utilizes a speech
therapist, occupational therapist, family psychologist, and other
professionals as necessary is crucial.
When documenting behavior, avoid generalizations such as
“Katie appears to have autistic tendencies or difficulty
communicating.” Instead, record specific behavior, for
example, “This afternoon we did not go outside because it was
raining—Katie threw the blocks and laid on the floor crying for
30 minutes and no amount of redirecting or consoling seemed
to help. I think I am beginning to see a pattern with Katie; she
has exhibited similar difficulty with changes in the schedule at
other times as well.”
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
Ready Resources
• Autism Society of America at www.autism-society.org
• Kami M. Talley Reading and Resource Center at the University
of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• ZERO TO THREE at www.zerotothree.org
Information included in this fact sheet comes from the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision) and DC:0–3R (Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood: Revised Edition).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Posttraumatic Stress
Disorder (PTSD)
About the Disorder
Young children who have been exposed to an event that is life
threatening (threatened death or serious injury), that is
perceived as life threatening, or that threatens the physical
safety of a caregiver can develop Posttraumatic Stress
Disorder (PTSD). The trauma may be a sudden unexpected
event, a series of connected events, or an enduring situation.
Typically, the traumatic experience is so overwhelming and
out of the ordinary compared to one’s usual experience that
one’s ability to cope is overpowered. A child with PTSD will
likely experience recurrent and intrusive thoughts and
memories of the traumatic event, they may have flashbacks
(a child may freeze or stare into space for a time), or they may
suffer physical stress when reminded of the event (pounding
heart, upset stomach). A child who has persistent symptoms
that interfere with daily functioning requires immediate
intervention.
Early Childhood
Mental Health Fact Sheet
about the trauma because they do not incorporate solutions
or alternative endings during their play. Also, the play will
be less imaginative than the child’s usual play. In addition,
some children may ask repeated questions about the subject
of the trauma. For example, a child who has been bitten by a
dog may ask numerous questions about dogs and may want
to look at pictures of dogs. These children will be distressed
but will still obsess about the topic of the trauma.
Symptoms of PTSD can sometimes be difficult to differentiate
from age-appropriate behaviors such as temper tantrums.
Frequency can also be difficult to determine because of
varying developmental levels—for example, how many
tantrums do 2 year olds usually have per week? Also be
aware that as the child processes the trauma, their memories
of the event may change because they are trying to make
sense of the events; as this processing continues and the child
begins to heal, allow for change in the story.
What You May See
After experiencing or re-experiencing a traumatic event,
young children will often appear very disorganized and
overwhelmed. Although infants do not have the ability to
communicate their distress verbally or through play, it
doesn’t mean they can’t experience PTSD. (See box for more
on emotional development.) For infants, the symptoms of
the disorder may be a difficulty in going to sleep or a pattern
of disrupted sleep, an exaggerated startle response, increased
irritability or fussiness, and/or intense separation anxiety.
A parent or caregiver may notice that the child sometimes
engages in post-traumatic play by reenacting the trauma;
unfortunately this type of play does not reduce their anxiety
Emotional Development During Early Childhood
Observable emotions develop throughout the first year of life.
Some emotions that are critical to the diagnosis of PTSD are
sadness, which develops around 3 months; recognizing fear in
others, which develops around 5 months; anger and surprise,
which develop around 6 months; and fear, which develops
around 9 months.
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
By the age of 9 months, infants are able to reproduce events
(behaviorally) from the day before, which indicates the
development of explicit memory. Though traumatic events
can be visualized with varying degrees of clarity and depth
perception depending on visual abilities developed during the
first 6 months, infants don’t have the developmental abilities
to express observable symptoms of PTSD until around 9
months of age.
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
Full verbal recollection (further development of explicit
memory) of a traumatic event is likely if the trauma occurs
after 28 to 36 months of age. A child will be able to give a full
narrative of what they understand/remember about trauma
event around that age. The behavioral expression of trauma is
also dependent on each child’s motor development.
IMPORTANT
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Posttraumatic Stress
Disorder (PTSD)
(continued)
Symptoms
• Preoccupied with the event
• Compulsively reenacting the event in play
• Paints, clay, dolls, and water play provide some children
with outlets for their feelings; incorporate this type of play
into your day.
• Exaggerated startle response
Documenting your Concerns and Next Steps
• Flashbacks
When documenting behavior, avoid generalizations such as
“Trevor seems anxious about loud noises.” Instead write
down what situations cause a child to have increased anxiety.
Recording the frequency of the behavior and what the child
said and did as well as what happened right before and after
the change in behavior can help identify areas of concern.
Also assess if there have been any traumatic events in the
child’s life. A parent may confide in you that the child
witnessed domestic abuse—if so, provide the parent with
resources in the community that can offer support and
guidance. It is also a good idea to have resources and fact
sheets on domestic abuse, substance abuse, and maternal
depression available for parents.
• Temporary loss of previously acquired developmental
skills, such as talking or toileting
• Increased irritability, outbursts of anger or extreme
fussiness, or temper tantrums
• Increased social withdrawal
• Aggression toward peers, adults, or animals
• Diminished interest in significant activities, including play,
social interactions, and daily routines
• Protest going to bed
• Repeated nightmares; night terrors
• Fear of the dark, fear of toileting alone, and other new
fears
• Constriction in play
Strategies
• Create a space of trust, safety, and acceptance; build trust
with the child.
• Be warm and welcoming.
• Use plenty of soothing techniques, holding, rocking,
and/or gentle talking (take into account the child’s
temperament when using these techniques).
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
• Give the child a lot of verbal empathy and support.
• Physical proximity of a trusted person may be necessary.
• Assist the child in developing an accurate narrative of the
traumatic event; correct misconceptions and distortions.
Use storytelling to help develop alternative endings.
• Avoid circumstances that are upsetting or re-traumatizing
for the child.
• If the child has an emotional response to a reminder of the
event or if the child appears to be re-living the event, help
the child to recognize that the emotion belongs to the past
and that it is not what is happening at the present time.
• Respond empathetically when a child loses a skill that they
had mastered before the traumatic event. Toilet training is
the most common in this category. Return to teaching the
skill to the child just as you had done the first time.
Ready Resources
• Kami M. Talley Reading and Resource Center at the
University of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• The
Posttraumatic
www.ptsdalliance.org
Stress
Disorder
Alliance
at
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• ZERO TO THREE at www.zerotothree.org
Information included in this fact sheet comes primarily from the DC:0–3R (Diagnostic Classification of Mental Health and Development Disorders of
Infancy and Early Childhood: Revised Edition).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Regulation Disorder of
Sensory Processing
About the Disorder
Young children with this disorder struggle to regulate their
emotions and behaviors as well as their motor abilities in
response to sensory stimulation. The sensory stimulation can
include touch, sight, sound, taste, smell, sensation of
movement in space, and awareness of the position of one’s
body in space. A child’s struggle with these sensory inputs
leads to impairment in their development and functioning.
These children have trouble maintaining a calm, alert, or
affectedly positive state. The three types of regulation
disorder of sensory processing are:
• hypersensitive, which has two subcategories—
fearful/cautious and negative/defiant;
• hyposensitive/under-responsive; and
• sensory stimulation-seeking/impulsive.
For all types of this disorder, parents report that their children
get upset easily, often lose their temper, have difficulty
adapting to change, are overly sensitive, and/or have a
difficult temperament.
What You May See
• Hypersensitive
These children experience sensory stimulation such as light
touch, loud noises, bright lights, and rough textures as
distressing. They may show an excessive startle reaction,
aggression, increased distractibility, and they may attempt to
escape from the stimulus. Infants may respond by being
irritable or fussy. They may not be comforted easily being
cuddled or sung to. In fact, these types of responses could be
what the child is reacting against. Parents and caregivers may
also notice hypersensitivity when trying to introduce new
foods to the child because of the child’s very low tolerance for
a variety of textures, tastes, and smells. As children with the
hypersensitive pattern mature, they typically display limited
interest in sensory motor play, engage in exploration less often
Early Childhood
Mental Health Fact Sheet
than is expected for their age, and exhibit difficulty in fine
motor coordination. All of this is usually due to the fact that
they self-limit activities because of their sensitivity.
Children with a hypersensitive sensory processing disorder
fall into one of two sub-categories, either fearful/cautious or
negative/defiant.
Children who show signs of the
fearful/cautious pattern will show stress when routines
change, are very shy and clingy in new situations, have a
limited ability to self soothe, and express excessive fears and
worries. These children are very cautious, inhibited, and
fearful. The negative/defiant hypersensitive child may
appear negativistic, stubborn, controlling, and will often do
the opposite of what is asked or expected. The child may be
slow to engage in new experiences, is aggressive when
provoked, and exhibits compulsiveness and perfectionism.
• Hyposensitive/Under-Responsive
These children require high-intensity sensory input before
they are able to respond. They are quiet and watchful at times
and may appear withdrawn and difficult to engage. Infants
may appear delayed or depressed and lack the desire to
explore their environment. As preschoolers, they often have
fewer words for dialogue and show a limited range of
behaviors, ideas, and fantasies. These children will seek out
activities that they know will provide them with adequate
sensory stimulus—they may spin on a sit-n-spin, swing for
long periods of time, or jump up and down on a bed. They
tend to show disinterest in exploring relationships, have poorquality motor skills, engage in limited exploratory activity,
and have limited flexibility when involved in activities.
• Sensory Stimulation-Seeking/Impulsive
Infants with this pattern will crave and seek sensory
stimulation. Preschoolers will appear excitable, have
intrusive behaviors, and exhibit a daredevil style. The motor
activities of these children are often unfocused so they may
appear clumsy due to poor motor planning.
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
These children may seem aggressive and fearless or
impulsive and disorganized. Their behavior patterns involve
high activity—for example, they will shriek with joy if you sit
on them because they seek contact and stimulation through
deep pressure. At times, this desire for contact coupled with
poor motor planning and disorganized motor skills can lead
to things being broken, unintended intrusions into others’
physical space, and unprovoked hitting. These actions are
often misinterpreted as aggressive, so other children may
respond with aggression, which may then lead the child with
the sensory stimulation-seeking/impulsive disorder to
develop aggressive behaviors.
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Regulation Disorder of
Sensory Processing
(continued)
Symptoms
Children who have difficulty regulating and processing
sensory input typically exhibit three features: 1) sensory
processing difficulties, 2) motor difficulties, and 3) a specific
behavioral pattern. A child with this disorder will be
sensitive (either over or under) to touch, sights, sounds,
smells, and sensations of movement in space.
• A child may be irritated by some types of clothes and shoes
• Give robust responses to the child’s cues, however slight
the cues may be.
For sensory stimulation-seeking/impulsive children:
• Provide the child with constructive opportunities for
sensory and affective involvement.
• Encourage and teach the child to recognize their own
limits, especially with regard to issues of safety.
• Bright, florescent lights may cause irritability or a meltdown
• Encourage the use of imagination and support exploration
of the external environment.
• A child may have a very limited diet and strongly resist
foods because of the texture
Documenting your Concerns and Next Steps
• Routine tasks, such as brushing teeth and combing and/or
cutting hair, may be nearly impossible to accomplish
• Toddlers may love or hate rough and tumble play
• A child may appear annoyed when touched too gently—in
infants, this may mean they won’t want to be cuddled or
they may prefer firm swaddling
• A child may have difficulty sleeping if a room isn’t
completely dark
Strategies
For all children:
• Show soothing and empathetic support of the child’s
individual needs.
• Announce transitions to the child who needs extra time to
adjust; when significant changes are happening (such as
moving to a new room), a slow and gradual change with
plenty of emotional support can help a child adjust.
• Show the child empathy and love. A caregiver who can
manage warmth even in the face of negativism or rejection
will help the child’s emotional development—it may take
time, but don’t give up!
• Help the child engage, attend to, interact with, and explore
the environment.
When documenting a child’s sensory sensitivities being very
observant and specific is especially important. For example,
noting that “Jonah rarely eats all his lunch” is not as
informative as “Jonah didn’t have yogurt at snack today, and
I noticed he rarely eats pudding when it’s packed in his
lunch.” Or saying that “Michelle washes her hands a lot” is
not as descriptive as “Michelle washes her hands
immediately after activities that involve paint or anything
gooey—even silly putty, which doesn’t stay on your hands.”
Keeping close tabs on when a child has an unusual response
to sensory stimuli may help to discover a pattern that will
help determine which sensory stimuli trigger a response.
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
For hypersensitive children:
• Provide quiet, calm spaces when possible.
• Watch for cues from the child that the environment is
overly stimulating (for example, some children love loud
noises, but a hypersensitive child may cover their ears).
• Find out the best way to show comfort, and help the child’s
peers to show comfort in similar ways (for example, let the
child’s peers know how close is too close).
For under-responsive children:
• Provide interactive input and exaggerated gestures.
Ready Resources
• Kami M. Talley Reading and Resource Center at the University
of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• ZERO TO THREE at www.zerotothree.org
• Reach out to the child; use animated expressions.
Information included in this fact sheet comes primarily from the DC:0–3R (Diagnostic Classification of Mental Health and Development Disorders of
Infancy and Early Childhood: Revised Edition).
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.
Early Childhood
Mental Health Fact Sheet
Tourette Syndrome
About the Disorder
Tourette Syndrome (TS) is a neurological disorder
characterized by tics—involuntary, rapid, sudden
movements and vocalizations (though they may not occur
simultaneously) that occur repeatedly in the same way. For
children with Tourette Syndrome (also known as Tourette’s
Disorder), onset typically occurs before 7 years of age, and
the disorder is usually recognized two to three years after
onset. In most children, the severity peaks at 9 to 11 years of
age. About 5 to 10 percent of children have an intensifying
course with little or no improvement. In about 85 percent of
children, symptoms diminish during and after adolescence.
The symptoms include:
• Both multiple motor and one or more vocal tic(s) present
at some time during the illness; however, the motor and
vocal tics may not necessarily occur simultaneously;
• The occurrence of tics many times a day (usually in bouts)
nearly every day or intermittently throughout a span of
more than one year; and
• Periodic changes in the number, frequency, type (vocal or
motor), and location of the tics; severity of the tics will wax
and wane; symptoms can sometimes disappear for weeks
or months at a time.
Research at the National Institute of Mental Health suggests
that some cases of TS (and related Obsessive Compulsive
Disorder) may be an auto-immune response triggered by
antibodies produced to counter strep infection. This
phenomenon is known as PANDAS. There is also a
confirmed genetic basis for TS; therefore, parents seeking
medical assistance for possible tic behavior in their children
IMPORTANT
This fact sheet is not intended to be used as a diagnostic tool.
It is meant to be used only as a reference for your own
understanding and to provide information about the different
kinds of behaviors and mental health issues you may
encounter.
should mention to their medical professionals any similar ticlike behaviors observed in other family members. Both
psychiatrists and neurologists are qualified to diagnose a case
of Tourette Syndrome.
What You May See
During infancy, symptoms of Tourette Syndrome are usually
not evident. Around age 3, a child may begin to show motor
or vocal tics. The most common first symptom in children
with Tourette Syndrome is a facial tic, such as rapidly
blinking eyes or twitches of the mouth. Tics of the limbs as
well as involuntary sounds such as throat clearing and
sniffing may also be initial signs. The tics, however, may be
somewhat difficult to recognize because speech patterns and
motor skills are still developing. By about age 4 when speech
patterns and motor development are well established, vocal
and motor tics may become more apparent. Vocal tics may
include vocal outbursts, imitating or echoing the words of
others, throat clearing, coughing, or snorting. Motor tics may
be as simple as blinking, wrinkling the nose, or lip licking; or
they may be as complex as arm or leg jerks, kicking, twirling,
or fist clenching. You may also see that a child who is
experiencing tics may be teased by others who don’t realize
that the tics are involuntary.
The complexity of some symptoms is often perplexing to
family members, friends, and others who may find it hard to
believe that the actions or vocal utterances are involuntary.
Tics do, over time, change and vary in severity. For example,
tics typically increase as a result of tension or stress, and
decrease with relaxation or when focusing on an absorbing
task. And although they can often be controlled or
suppressed for brief periods of time, they are experienced as
irresistible and, as with the urge to sneeze, eventually must
be expressed.
Symptoms
• Repetitive eye blinking
• Repetitive clearing of the throat
• Repetitive coughing
• Repetitive lip licking
While it is important to respect a child’s need for
confidentiality, if you work with children or families, you are
legally required to report suspected child abuse or neglect.
For more information, consult “Reporting Child Abuse and
Neglect: A Resource Guide for Mandated Reporters,” available
from the Minnesota Department of Human Services.
• Repetitive fist clenching
• Imitating or echoing the words of others
• Imitating or echoing the motions of others
• Leg jerks
• Vocal outbursts
Minnesota Association for Children’s Mental Health • MACMH
165 Western Avenue N, Suite 2, St. Paul, MN 55102 • 800-528-4511 • 651-644-7333 • www.macmh.org
Tourette Syndrome
(continued)
Strategies
• Interventions for a child with Tourette Syndrome should
emphasize teaching the child to successfully navigate
developmentally appropriate tasks. The goals should be to
help the child develop friendships, experience trust, and
feel competent completing activities—not stopping the tics.
• Teach relaxation and deep breathing exercises to children
who are able to understand and participate in these
techniques. Blowing bubbles and pretending to blow
bubbles, learning to whistle, or actively trying to move
their bellies in and out are all fun ways for children to
learn deep breathing.
• Teach the child to tune into and identify their emotions
and levels of frustration—increased frustration or anxiety
can cause an increase in tic behaviors.
Common Co-Occurring Disorders with Tourette
Syndrome • (adapted from www.tsa-usa.org)
Some children who have Tourette Syndrome (TS) may also
have other mental health concerns.
Obsessive Compulsive Disorder (OCD)
Children may have repetitive thoughts that can become
unwanted or bothersome, or they may feel compelled to do
something over and over and/or in a certain way. Examples
include touching an object with one hand after touching it
with the other hand to “even things up” or begging for a
sentence to be repeated many times until it “sounds right.”
Attention-Deficit/Hyperactivity Disorder (AD/HD)
AD/HD occurs in many people with TS. Children may show
signs of hyperactivity before TS symptoms appear. Indications
of AD/HD may include difficulty with concentration, failing to
finish what is started, not listening, acting before thinking,
shifting constantly from one activity to another, needing a
great deal of supervision, and general fidgeting. AD/HD
without hyperactivity includes all of the above symptoms
except for the high level of activity.
Difficulties with impulse control may result, in rare
instances, in overly aggressive behaviors or socially
inappropriate acts. Also, defiant and angry behaviors can
occur.
Sleep Disorders are fairly common among people with TS.
These include difficulty getting to sleep, frequent
awakenings, or walking or talking in one’s sleep.
• Do not punish the child for engaging in tics or what may
appear to be strange habits such as lip licking or excessive
blinking.
• Because stress can cause a child’s tics to increase, simplify the
child’s environment and take steps to avoid sensory triggers
such as bright lights, loud noises, or chaotic activity.
Documenting Your Concerns and Next Steps
When recording information about a child who appears to
have tics, being very observant and specific is especially
important. Because tics can be related to frustration and
anxiety, it is also helpful to record what was happening just
before the tics occurred. Avoid generalizations such as “It
seems like Stephan licks his lips all day.” Instead try to
associate specific events with tic behavior. For example,
noting that “Stephan seemed to lick his lips when he couldn’t
find the last piece to the puzzle” may give more information
about what triggers tics in Stephan. Recording the frequency
of the tics as well as what the caregiver said and did can help
to identify areas of concern.
If a child’s behaviors are causing concern, you may want to
suggest to the parents that they take their child to their
primary care provider who may refer the parents to a mental
health professional, an early childhood behavior specialist, or
a developmental pediatrician. When discussing your
concerns, focus on the child’s behaviors and avoid drawing
conclusions about whether the behaviors are indicative of a
mental health problem.
For more information about early childhood mental health,
see MACMH’s A Guide to Early Childhood Mental Health,
available for order at www.macmh.org.
Ready Resources
• Kami M. Talley Reading and Resource Center at the
University of Minnesota offers a bibliography of resources at
http://education.umn.edu/ChildCareCenter/Kamihealing
throughbooks/
• National Institute of Mental Health at www.nimh.nih.gov
• SAMHSA’s National Mental Health Information Center at
www.mentalhealth.samhsa.gov
• Tourette Syndrome Association at www.tsa-usa.org
• ZERO TO THREE at www.zerotothree.org
Some of the information for this fact sheet came from the Tourette’s Syndrome Association.
Funding for the development and publication of this fact sheet was sponsored in part by a grant from the Minnesota Department of Education
using federal dollars from CFDA 84.323A, Special Education - Program Improvement Grants.